- Eligibility for VIVITROL® Co-pay Savings Program (Program): This Program is only available to patients 18 years or older with a valid VIVITROL prescription. This Program is not available to patients who are enrolled in, or covered by, any local, state, federal or other government program that pays for any portion of medication costs, including but not limited to Medicare (including Medicare Part D), Medicaid, Medigap, VA, DOD, TRICARE, or a residential correctional program. Patients who become eligible for any government program that pays for any portion of medication costs will no longer be eligible for this Program. Patients must live in the United States or Puerto Rico. Patients must meet the Program requirements every time they use the VIVITROL Co-pay Savings Card.
- Program Benefit: Eligible patients may pay as little as $0 per prescription of VIVITROL. Maximum savings per prescription is $500.00 up to 12 prescriptions per calendar year, with maximum savings up to $6,000 per calendar year. After reaching the maximum Program benefit amounts, patients are responsible for any remaining out-of-pocket costs for VIVITROL. Eligible patients may receive benefits for valid claims submitted with a date of service that is up to 90 days prior to the initial enrollment date. The Program assists with the out-of-pocket cost for VIVITROL only. It does not assist with any other out-of-pocket costs (e.g., for the office visit or medication administration) even if such costs are associated with VIVITROL administration. All Program payments are for the benefit of the patient only. The VIVITROL Co-pay Savings Card expires after 5 years but may be renewed if all eligibility criteria are met.
- Additional Terms of Use: This Program is not conditioned on any past, present, or future purchase, including refills. To use this Program, the participating patients are responsible for following any health plan requirements, including any requirements, if any, to inform the health plan how much co-payment support they get from this Program. This Program may be subject to health plan benefit design requirements. Alkermes may rescind, revoke, or amend this Program offer, eligibility, benefits, and requirements at any time without notice, including in specific states. This Program is limited to one per patient and may not be used with any other coupon, discount, prescription savings card, free trial, or other offer. This Program is not transferable. Patients may not seek payment for the value received through the Program from any health plan, patient assistance foundation, flexible spending account, or healthcare savings account. Void where prohibited by law, taxed, or otherwise restricted. The Program is not insurance. Program Administrator or its designee will have the right upon reasonable prior written notice, during normal business hours, and subject to applicable law, to audit compliance with this program.
- Use and Disclosure of Information: Before the VIVITROL Co-pay Savings Card is activated, the patient will be asked to provide personal information that may include their name, date of birth, type of insurance, and contact information. This information is needed for the Program Administrator and its service providers to enroll the patient in the VIVITROL Co-pay Savings Program. Data shared with Alkermes by the Program Administrator will be aggregated and de-identified and may be used by Alkermes for its own internal business purposes and/or to improve or modify the Program. Program Administrator will not share the patient’s personal information with anyone else except where legally permitted. For more information, see Alkermes’ Privacy Policy at www.alkermes.com/privacy.
- To the Patient: When using the VIVITROL Co-pay Savings Card, you certify that you understand and agree to comply with the above Terms and Conditions and that you meet, or are the legal guardian of a patient who meets, the Program eligibility requirements. For questions about your eligibility or benefits, if your insurance has changed, or if you wish to discontinue your participation, call the VIVITROL Co-Pay Savings Program at 1-800-848-4876 (8:00 AM-8:00 PM ET, Monday-Friday).
- To the Pharmacist: When using the VIVITROL Co-pay Savings Card, you certify that you will comply with the above Terms and Conditions and the Program eligibility criteria and that you have not submitted and will not submit a claim for reimbursement under any local, state, federal, or other government program for this prescription. For commercially insured patients, submit claim to the patient’s commercial insurance plan as primary coverage. Upon response from the insurance plan, submit the co-pay authorized by the patient’s primary insurance using the VIVITROL Co-pay Savings Card information as secondary coverage, and transmit using the COB segment of the NCPDP transaction as a secondary claim to IQVIA using BIN 601341. For cash paying patients, submit as a primary claim using the VIVITROL Co-pay Savings Card information to IQVIA using BIN 601341. Applicable discounts will be displayed in the transaction response. For questions regarding setup, claim transmission, patient eligibility, or other issues, call the program support line for the VIVITROL Co-pay Savings Program at 1-877-838-3836 (8:00 AM-8:00 PM ET, Monday-Friday).
VIVITROL is not right for everyone. There are significant risks from VIVITROL treatment, including risk of opioid overdose, severe reaction at the injection site, sudden opioid withdrawal, liver damage, or hepatitis.
Talk to your healthcare provider about naloxone, a medicine that is available to patients for the emergency treatment of an opioid overdose.
Call 911 or get emergency medical help right away in all cases of known or suspected opioid overdose, even if naloxone is administered.
If you are being treated for alcohol dependence but also use or are addicted to opioid-containing medicines or opioid street drugs, it is important that you tell your healthcare provider before starting VIVITROL to avoid having sudden opioid withdrawal symptoms when you start VIVITROL treatment.
See Important Safety Information.
See Prescribing Information and Medication Guide.
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